Read and answer question in details
NotAllF
Article2.pdf
New York City COVID-19 resident physician exposure during exponential phase of pandemic
Mark P. Breazzano, … , Alice Chen-Plotkin, Royce W.S. Chen
J Clin Invest. 2020. https://doi.org/10.1172/JCI139587.
In-Press Preview
Background
From March 2-April 12, 2020, New York City (NYC) experienced exponential growth of the COVID-19 pandemic due to novel coronavirus (SARS-CoV-2). Little is known regarding how physicians have been affected. We aimed to characterize COVID-19 impact on NYC resident physicians.
Methods
IRB-exempt and expedited cross-sectional analysis through survey to NYC residency program directors (PDs) April 3–12, 2020, encompassing events from March 2–April 12, 2020.
Results
From an estimated 340 residency programs around NYC, recruitment yielded 91 responses, representing 24 specialties and 2,306 residents. 45.1% of programs reported at least one resident with confirmed COVID-19: 101 resident physicians were confirmed COVID-19-positive, with an additional 163 residents presumed positive for COVID-19 based on symptoms but awaiting or unable to obtain testing. Two COVID-19-positive residents were hospitalized, with one in intensive care. Among specialties with >100 residents represented, negative binomial regression indicated that infection risk differed by specialty (p=0.039). 80% of programs reported quarantining a resident. 90/91 programs reported reuse or extended mask use, and 43 programs reported that personal protective equipment (PPE) was suboptimal. 65 programs (74.7%) have redeployed residents elsewhere to support COVID-19 efforts.
Conclusion
Many resident physicians around NYC […]
Clinical Medicine COVID-19
Find the latest version:
https://jci.me/139587/pdf
1
TITLE:
New York City COVID-19 resident physician exposure during exponential phase of
pandemic
AUTHOR BLOCK:
Mark P. Breazzano1–3, Junchao Shen4, Aliaa H. Abdelhakim1–3, Lora R. Dagi Glass1,
Jason D. Horowitz1, Sharon X Xie5, C. Gustavo de Moraes1, Alice Chen-Plotkin4, Royce
W. S. Chen1, on behalf of the New York City Residency Program Directors COVID-19
Research Group
AFFILIATIONS:
1Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University
Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
2Department of Ophthalmology, New York University School of Medicine, New York
University Langone Health, New York, NY, USA
3Manhattan Eye, Ear and Throat Hospital, Lenox Hill Hospital, Northwell Health, New
York, NY, USA
4Department of Neurology, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
5Department of Biostatistics, Epidemiology and Informatics, Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA, USA
2
*CORRESPONDENCE:
Royce W. S. Chen, M.D.
Helen and Martin Kimmel Assistant Professor of Clinical Ophthalmology
Divisions of Vitreoretinal Surgery and Uveitis
Columbia University Irving Medical Center
New York-Presbyterian Hospital
635 W 165th St
New York, NY 10032
Tel: 212-305-9535
Fax: 212-305-5523
Email: [email protected]
Conflict of Interest Statement:
The authors have declared that no conflict of interest exists.
3
ABSTRACT:
Background
From March 2-April 12, 2020, New York City (NYC) experienced exponential growth of
the COVID-19 pandemic due to novel coronavirus (SARS-CoV-2). Little is known
regarding how physicians have been affected. We aimed to characterize COVID-19
impact on NYC resident physicians.
Methods
IRB-exempt and expedited cross-sectional analysis through survey to NYC residency
program directors (PDs) April 3–12, 2020, encompassing events from March 2–April 12,
2020.
Results
From an estimated 340 residency programs around NYC, recruitment yielded 91
responses, representing 24 specialties and 2,306 residents. 45.1% of programs
reported at least one resident with confirmed COVID-19: 101 resident physicians were
confirmed COVID-19-positive, with an additional 163 residents presumed positive for
COVID-19 based on symptoms but awaiting or unable to obtain testing. Two COVID-19-
positive residents were hospitalized, with one in intensive care. Among specialties with
>100 residents represented, negative binomial regression indicated that infection risk
differed by specialty (p=0.039). 80% of programs reported quarantining a resident.
90/91 programs reported reuse or extended mask use, and 43 programs reported that
4
personal protective equipment (PPE) was suboptimal. 65 programs (74.7%) have
redeployed residents elsewhere to support COVID-19 efforts.
Conclusion
Many resident physicians around NYC have been affected by COVID-19 through direct
infection, quarantine, or redeployment. Lack of access to testing and concern regarding
suboptimal PPE are common among residency programs. Infection risk may differ by
specialty.
Funding
AHA, MPB, RWSC, CGM, LRDG, JDH: NEI Core Grant P30EY019007, RPB
Unrestricted Grant. ACP and JS: Parker Family Chair. SXX: University of Pennsylvania.
5
INTRODUCTION:
The United States (US) is part of a global pandemic known as COVID-19,(1) with
characteristics overlapping with the Spanish flu of 1918 more than a century earlier. The
causative novel coronavirus (2019-nCoV, SARS-CoV-2), first described in Wuhan,
China,(2,3) has spread worldwide, particularly in New York City (NYC), which is
currently the US epicenter of cases and mortality.(4) The first case was confirmed in
NYC on March 1, 2020;(5) six weeks later, hundreds of patients are dying from COVID-
19 daily.(6) Healthcare workers (HCW) are on the front lines of this pandemic.(2,7)
However, although at least 4,500 peer-reviewed articles have been published on this
topic between January 1, 2020 and April 18, 2020, comparatively little is known about
the toll of COVID-19 on healthcare workers directly occupied with patient care.
Notably, the first physician to sound the alarm about the novel coronavirus causing
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was the Chinese
ophthalmologist Li Wenliang, who died after infection by a pre-symptomatic patient.(8)
Anecdotally, HCW in NYC have experienced unique challenges in combatting the
illness, including close contact with the sickest patients, exposure to high viral loads,
redeployment to clinical duties outside of their ordinary responsibilities, and severe
shortages in personal protective equipment (PPE).(7,9,10) Among those at highest risk
are resident physicians, who are commonly stationed in high-acuity settings and
comprise a substantial part of the healthcare workforce in the United States.(11) The
activities of resident physicians are standardized among residency training programs
throughout the US via accreditation with the Accreditation Council for Graduate Medical
6
Education (ACGME), with each residency program supervised by an appointed program
director.(12) The structure of residency programs, with many resident physicians
reporting to one program director responsible for their activities and well-being, makes
the resident physician population practical for study through collection of data from
residency program directors. However, to our knowledge, no primary peer-reviewed
data has addressed implications of COVID-19 for resident physicians, whose situation
has only been described in editorials.(13,14) We also sought to explore whether
specialty-specific risks existed for COVID-19 infection. By surveying residency program
directors among all departments within NYC from April 3-12, 2020, we captured the
immediate features and impact of COVID-19 among resident physicians during the
exponential phase of the COVID-19 pandemic in NYC. As future or recurrent outbreaks
are likely, such knowledge may help tailor future interventions to mitigate the burden of
COVID-19 among HCWs.
7
RESULTS:
Study sample
102 program director responses were received between April 3 and April 12, 2020, 10
of which were excluded because the represented programs did not satisfy residency
and ACGME-accreditation criteria (i.e. they were fellowship rather than residency
programs), and one of which was removed as it was incomplete and reported zero
residents in the program. Thus, 91 programs representing 2,306 residents from 24
different specialties were included in this study (Figure 1). Average program size was
25 residents (standard deviation [S.D.] = 21), with a range of 1 – 98 residents per
program. 49 programs (53.8%, 95% CI 43.1-64.4) reported that residents provided
services for >3 different hospitals.
Overall cases and testing frequency of COVID-19
All 91 program directors reported numbers for symptomatic residents who had tested
positive for COVID-19 (“confirmed” cases). 90/91 program directors reported numbers
for symptomatic residents who were awaiting or unable to obtain testing (“presumed”
cases) and symptomatic residents who had tested negative for COVID-19 (“suspected”
cases). In total, 41/91 (45.1%, 95% CI 34.6-55.8) programs reported at least one
confirmed case, 49/90 programs (54.4%, 95% CI 43.6-65.0) reported at least one
presumed case, and 36/90 programs (40%, 95% CI 29.8-50.9) reported at least one
suspected case. Among all residents from all programs pooled together, 101 residents
were confirmed cases, 163 were presumed cases, and 76 were suspected cases
8
(Figure 2). The total number and proportion of affected residents by specialty are
shown in the Table.
86/91 program directors reported knowing how many residents were tested for COVID-
19. Among the 2,088 residents in these 86 programs, a total of 242 residents (11.6%,
95% CI 10.2-13.0) were tested for COVID-19. 177 residents who were tested also had
results reported by the time of the survey. Among these, 101 (57.1%, 95% CI 49.4%-
64.5) tested positive and 76 (42.9%, 95% CI 35.5- 50.6) were negative.
69/91 program directors reported knowing the exact number of residents who were
tested for COVID-19 as well as whether residents were awaiting testing. Among 1,673
residents in these 69 programs, 113 residents (6.8%, 95% CI 5.6-8.1) were waiting for
or unable to obtain testing. 39 (56.5%, 95% CI: 44.0- 68.4) residency programs had at
least 1 resident waiting for or unable to get testing.
For residents who tested positive for COVID-19 as well as those who tested negative,
the majority of testing was performed with RT-PCR of samples collected by nasal swab
(n=85 [84.2%] for test-positive; n=59 [77.6%] for test-negative), followed by
oropharyngeal swab (n=5 [5.2%] for test-positive; n=6 [7.9%] for test-negative).
Disease burden by specialty
To determine whether any specific medical specialties were more likely to have a
COVID-19 positive resident, all specialties with more than 100 residents in our sample
9
were compared. Programs that met this criterion included anesthesiology, emergency
medicine, general surgery, internal medicine, ophthalmology, pediatrics, and psychiatry
(Figure 1). Three specialties (anesthesiology, emergency medicine, ophthalmology)
appeared to cluster as high-risk specialties by proportion of residents with confirmed
COVID-19, compared to the remaining specialties (p=0.015, Fisher’s exact test). In
negative binomial models adjusted for the size of the residency program and date of
survey completion, specialty remained significantly associated with the number of
confirmed positive residents (p= 0.039). Using anesthesiology as the reference group
(as this specialty had the highest proportion of positive residents), anesthesiology was
significantly more likely to have a COVID-19 confirmed resident, compared to both
internal medicine (p= 0.020) and pediatrics (p = 0.029).
Timing of symptom onset
Symptom onset was reported to occur as early as or prior to the week of March 2–8,
2020 for 5 residents (1.5%) with confirmed (n=1), presumed (n=3), or suspected (n=1)
COVID-19 (Figure 3). Most residents with confirmed COVID-19 (35, 34.7%, 95% CI
25.5-44.8) were reported to first experience symptoms the week of March 22–28, 2020.
By contrast, most with presumed (53, 32.5%, 95% CI 25.4-40.3) and suspected (29,
38.2%, 95% CI 27.2-50.0) COVID-19 reported symptoms beginning the week of March
15–21, 2020. Symptom onset for affected residents among every category (confirmed:
n=3 [3.0%], presumed: n=3 [1.8%], suspected: n=1 [1.3%]) continued through the last
week of survey participation, April 6–12, 2020.
10
Personal protective equipment (PPE)
The majority of programs, encompassing 1,832 residents (79.4%, 95% CI 77.7-81.1)
used either N95 or surgical masks during patient encounters, depending on the context.
Nineteen programs, encompassing 323 residents (14%, 95% CI 12.6-15.5) used only
surgical masks during patient encounters; and 8 programs, encompassing 31 residents,
(5.7%, 95% CI 4.8-6.7) used an N95 respirator for all patient encounters. Excepting one
radiology program, all programs, encompassing 99.2% of residents in this study,
reported reuse or extended use of their masks (vs. single-use). Protocols mandating
universal wearing of surgical masks were introduced as early as the week of March 2–8,
2020 in only 3 programs (3.5%), and as late as March 30–April 5, 2020 in 20 programs
(23.5%, Figure 3).
43/87 program directors (49.4%, 95% CI 38.5-60.4) representing 1,314 residents
answered “yes” when asked whether their residents had had to work with suboptimal
PPE. We found no correlation between the mask type used by residents (surgical, N95,
or both) and perceived shortage of PPE. We found no correlation between programs
that reported suboptimal PPE and number of COVID-19 positive residents.
Care Setting and Hospitalization
Among the 101 residents with confirmed COVID-19, 57 (56.4%, 95% CI 46.2-66.3)
presented to clinic or primary care, 17 (16.8%, 95% CI 10.1-25.6) visited the emergency
department, 2 (2.0%, 95% CI 0.2-7.0) were hospitalized, and 1 (1%, 95% CI 0-5.4) had
care escalated to the intensive care unit (ICU). The 163 residents with presumed
11
COVID-19 presented to primary care or clinic in 40 cases (24.5%, 95% CI 18.1-31.9)
and the emergency department in 6 cases (3.7%, 95% CI 1.4-7.8). Among the 76
residents with suspected COVID-19, 38 (50%, 95% CI 38.3-61.7) were evaluated in
clinic or by primary care, 5 (6.5%, 95% CI 2.2-14.7) presented to emergency
department, and 1 (1.3%, 95% CI 0-7.1) was hospitalized. In total, among the 340
residents with confirmed, presumed or suspected COVID-19, 3 (0.9%, 95% CI 0.2- 2.6)
were hospitalized (1 each from emergency medicine [who was also hospitalized and
went to the ICU], ophthalmology, and psychiatry programs; 2 were confirmed, and 1
suspected COVID-19). There were no deaths reported in any of the completed surveys.
Quarantine
One program (pediatrics) of 58 residents did not report any quarantine data. Of the
remaining 90 programs encompassing 2,248 residents (including 339 residents with
confirmed, presumed, or suspected COVID-19 infection), 377 (16.8%, 95% CI 15.2-
18.4) residents from 72 programs (80% of programs, 95% CI 70.2-87.7) were reported
to be quarantined. 22 programs (24.4%, 95% CI 16.0-34.6) reported at least one
asymptomatic, but exposed, resident, who was quarantined. Among 34 asymptomatic
but exposed residents with known duration of quarantine, the time ranged from 1 – 14
days. 15 residents (14.9%, 95% CI 8.6-23.3) from 2 programs with confirmed COVID-
19, 26 residents (16.0%, 95% CI 10.8-22.6) from 5 programs with presumed COVID-19,
and 5 residents (6.6%, 95% CI 2.2-14.7) from 2 programs with suspected COVID-19
were not quarantined.
12
Redeployment
87/91 program directors responded to questions about residents redeployed to other
departments or locations to support COVID-19 efforts. 65 programs (74.7%, 95% CI
64.3-83.4) reported at least one resident redeployed, with 35 (40.2%, 95% CI 29.9-51.3)
programs redeploying more than one-third of their workforce. 594 residents (27.3% of
2,176 residents for whom redeployment information is known, 95% CI 25.4-29.2) were
reported to be redeployed. Anesthesiology had the highest redeployment rate, with 158
(56.0% of 282 total anesthesiology residents, 95% CI 50.0-61.9) residents being
redeployed to other services (p<0.001, Pearson’s chi-squared test). Of programs that
redeployed residents, 53 programs (81.5%, 95% CI 70.0-90.1) instituted redeployment
between the fourth and fifth weeks of March, approximately 1 month after the first case
in NYC was confirmed. Among residents redeployed to duties beyond their usual clinical
responsibilities, the majority went to the ICU (283/594 redeployed residents, 47.6%,
95% CI 43.6-51.7), followed by hospital floors (176/594, 29.6%, 95% CI 26.0-33.5), and
the emergency department (85/594, 14.3%, 95% CI 11.6-17.4).
13
DISCUSSION:
As of the date of our survey’s close, NYC is the epicenter of the COVID-19 pandemic in
the US, and the daily death toll continues to rise.(6) Here, we report the impact of
COVID-19 on NYC resident physicians, as reported by their residency program
directors, surveyed between April 3-12, 2020. Many of these residents have been
directly infected (101 confirmed positive), quarantined (16.8% of residents), or
redeployed (27.3% of residents) to duties outside of their usual clinical activities in
support of COVID-19 efforts.
101 residents were reported to have confirmed COVID-19 in our sample. While this is
4.4% of the 2306 residents whose program directors participated in our study, the true
rate in our sample may be higher, since 242 resident physicians were tested for COVID-
19, and only 177 had received their test results at the close of the survey.
We highlight a few points found in our study. First, program directors reported 15
confirmed COVID-19 residents and 26 presumed COVID-19 residents who were not
quarantined. Whether this was due to these residents being initially asymptomatic,
workforce need, delay in obtaining testing, or some other reason is not known.
However, we do note that 56.5% of residency program directors reported at least one
resident awaiting or unable to obtain COVID-19 testing. Second, 49.4% of residency
directors answered “yes” to the question of whether resident physicians for whom they
were responsible had suboptimal PPE. While this might reflect selection bias with
respect to which residency directors chose to answer the survey, we note that 90/91
14
programs reported reuse or extended use of masks that are ordinarily disposable after a
single use. Third, we find that some specialties may be at greater risk for contracting
COVID-19 compared to others. In particular, anesthesiology had significantly higher
numbers of confirmed COVID-19 residents than several other specialties. It is possible
that the higher infection rates may be due to the critical skill of intubation provided by
anesthesiologists, which comes with high probability of aerosolization and exposure to
viral particles.(15)
Emergency room physicians and Ophthalmologists may also be at higher risk for
infection. Given that emergency room physicians may intubate and are often the first-
line providers for infected patients before COVID-19 status is known, it is not surprising
that they segregrate as a higher risk group. Factors possibly placing ophthalmologists at
higher risk include close proximity to the patient’s upper respiratory tract during slit lamp
examination (usually less than one foot),(16) contact with ocular secretions,(16,17) and
high volume of patients seen in clinics.
We recognize limitations to our current study. While not all presumed and suspected
cases have COVID-19, we present these numbers given the high pre-test probability of
infection in HCW with suggestive symptoms, as well as known limitations of RT-PCR
detection of the virus.(18,19) Future work using serological testing may provide a more
accurate census of confirmed positives, as recent studies have shown,(20) but given
the limited availability of serological testing and the time-sensitive nature of our survey,
this modality was not suitable for the current study. Second, we were unable to
15
determine a relationship between mask type and proportion of COVID-19 infections for
the following reasons. During the period of the study, national and local guidelines on
PPE usage were continually changing based on availability and increased
understanding regarding disease transmission. In addition, the majority of programs
reported using both types of masks, depending on clinical context. Third, selection bias
may have affected our findings, as fields such as ophthalmology may have been over-
represented due to the authors’ connections to colleagues in this field, while other
specialties, such as internal medicine, may have been under-represented because of
significant stress in managing overflowing COVID-19 wards and lack of time to
complete the survey. It is also possible that program directors whose residents have
been affected by COVID-19 would be more likely to respond. Therefore, rates of
infection per specialty may need to be interpreted with caution.
However, we capture 91 NYC residency programs (out of an estimated 340 total
residency programs) during a period of exponential pandemic growth, offering a unique
perspective on the impact on resident physicians during what may be the height of
COVID-19 in NYC. Indeed, capturing the experience as it happens avoids recall bias
after the fact. It is our hope that this insight may allow locations not yet as substantially
affected by COVID-19 to better anticipate the needs of resident physicians, who are
truly at the front lines of an unprecedented challenge.
16
METHODS:
Recruitment of program directors
Recruitment of residency program directors throughout the greater NYC area was
performed through circulation of electronic mail message sent by one investigator at
Columbia University Irving Medical Center (R.W.S.C.), with responses received from
April 3, 2020 through April 12, 2020. Identification of programs, respective program
directors, and contact electronic mail addresses were retrieved from either previous
correspondence or publicly available search tools with ACGME via hyperlink
(https://apps.acgme.org/ads/Public/Programs/Search). The survey was first distributed
to 12 ophthalmology residency program directors in the greater NYC area, who
expanded distribution to 188 additional non-ophthalmology training programs within
their own institutions. As a second method, 303 programs identified separately in the
ACGME database by two authors (M.P.B., A.H.A.) were also contacted electronically.
Ultimately, at least one contact attempt was made at every known residency training
program in the greater NYC area (approximately 340 total), as our two approaches may
have overlapped. Repeat contact for increased yield was not made because: 1. Initial
feedback from designated institutional officials at some centers included concern for the
potentially stressful nature of the survey despite institutional review board (IRB)
approval, and 2. Prolonging data collection time may have confounded results by
including responses obtained outside of the pandemic exponential phase, introducing
an element of recall bias.
Survey of resident physician experience
17
An anonymous survey (Supplemental Content) eliciting de-identified information was
included in circulated electronic mail message by hyperlink with SurveyMonkey® cloud-
based software (SurveyMonkey®, San Mateo, CA, USA). More than one survey
completion by the same user was prohibited, both by request within the recruitment
electronic message and based on internet protocol address.
Diagnosis or suspicion of COVID-19 among residents was elicited in our survey based
on clinical presentation with symptoms including: sore throat, cough, fever, shortness of
breath, chest pain, myalgia, malaise, conjunctivitis, anosmia, or gastrointestinal
symptoms. Survey questions pertained to 3 distinct groups among resident doctors: (1)
“confirmed” – defined as resident physicians with COVID-19 symptoms and positive test
results; (2) “presumed” – defined as resident physicians with COVID-19 symptoms
without test results, and (3) “suspected” – defined as resident physicians with COVID-19
symptoms and negative test results. Suspected cases were tallied in our analysis due to
the relatively high false negative rate of reverse transcription polymerase chain reaction
(RT-PCR) testing for active infection by this virus15,16 as well as high pre-test probability
for COVID-19 in the context of suggestive symptoms, due to HCW status and NYC
location.
Inclusion and exclusion of responses
Responses were reviewed for inclusion based on specific training program. Fellowship
programs were excluded from the analysis. Because certain specialties have programs
that exist as a residency-fellowship continuum, these training programs with ACGME
18
accreditation were included. We did not distinguish between these integrated programs
and residency-only programs. All programs included were ACGME-accredited, with the
exception of oral maxillofacial surgery (OMFS), which was included as many OMFS
programs offer clinical experience through ACGME-accredited rotations such as general
surgery, ultimately leading to medical licensure with or without an M.D. degree, in
addition to pre-existing dental licensure. Programs were included if within or
immediately adjacent to NYC. All queried programs but one were centralized within 30
miles of Central Park in Manhattan, verified by Google Maps with hyperlink:
https://www.google.com/maps (Google Inc., Mountain View, CA, USA) for distance
calculations which used mailing addresses from primary affiliations for each recipient of
the survey.
Statistics
Proportions are reported as percentages with 95% confidence interval (CI) calculated
using the Clopper-Pearson approach.
Specialties with representation by 100 or more residents were selected for further
between-specialty analyses. Because the number of COVID-19 positive residents by
individual programs were count outcomes and non-normally distributed, Poisson
regression and negative binomial regression were fitted to determine whether specialty,
program size, or date of survey response affected the number of residents with positive
COVID-19 tests. Likelihood ratio (LR) testing was used to determine the
appropriateness between Poisson regression and negative binomial regression.
19
Fisher’s exact test was used to assess the overall effect of specialties on the proportion
of residents with confirmed COVID-19. Pearson’s chi-squared test was used to compare
infection rate and redeployment rate between departments. Correction for multiple
comparisons was made with Bonferroni procedures.
Statistical analyses were performed in the R programming language (Version.1.2.5042).
Type 1 error was defined at the 5% level for hypothesis testing with two-tailed
probabilities.
Study Approval
The need for subject consent was waived due to minimal risk, anonymous nature, and
lack of sensitive information in the study design as per Columbia University IRB
expedited exemption protocol IRB-AAAS9946. All procedures were reviewed and in
accordance with the tenets of the Declaration of Helsinki.
20
AUTHOR CONTRIBUTIONS:
Project concept (MPB, AHA, JDH, and RWSC); survey design (MPB, JS, AHA, LRDG,
JDH, CGM, ACP, and RWSC); data collection (MPB, JS, AHA, RWSC, and New York
City Residency Program Directors COVID-19 Research Group); data interpretation
(MPB, JS, AHA, LRDG, JDH, SXX, 11 CGM, ACP, and RWSC); figure preparation
(MPB, JS, and RWSC) and manuscript preparation (MPB, JS, AHA, LRDG, JDH, SXX,
CGM, ACP, and RWSC).
21
ACKNOWLEDGMENTS:
We thank Julia A. Kucherich, RD, for contributing to survey design and discussion
references. See Supplemental Acknowledgments for consortium details.
22
REFERENCES:
1. Novel Coronavirus (2019-nCoV): Situation Report – 11. World Health
Organization. https://www.who.int/docs/default-source/coronaviruse/situation-
reports/20200131-sitrep-11-ncov.pdf?sfvrsn=de7c0f7_4. Updated January 31,
2020. Accessed May 16, 2020.
2. Chen N, et al. Epidemiological and clinical characteristics of 99 cases of 2019
novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet.
2020;395(10223):507-513.
3. Li Q, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-
infected pneumonia. N Engl J Med. 2020;382:1199-207.
4. Coronavirus in the US: Latest COVID-19 news and case counts. Live Science.
https://www.livescience.com/coronavirus-updates-united-states.html. Updated
May 15, 2020 Accessed: May 16, 2020.
5. West MG. First case of coronavirus confirmed in New York State. Wall Street
Journal. https://www.wsj.com/articles/first-case-of-coronavirus-confirmed-in-new-
york-state-11583111692. Updated March 1, 2020. Accessed May 16, 2020.
6. NYC Health. COVID-19: Data: Daily Counts.
https://www1.nyc.gov/site/doh/covid/covid-19-data.page. Updated May 16, 2020.
Accessed May 16, 2020.
7. Wang X, Zhang X, He J. Challenges to the system of reserve medical supplies
for public health emergencies: reflections on the outbreak of the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic in China. BioSci
Trends. 2020;14(1):3-8.
23
8. Buckley C. Chinese doctor, silenced after warning of outbreak, dies from
coronavirus. The New York Times. https://nyti.ms/375KzwH. Updated February
7, 2020. Accessed May 16, 2020.
9. Paulo AC, Correia-Neves M, Domingos T, Murta AG, Pedrosa J. Influenza
infectious dose may explain the high mortality of the second and third wave of
1918–1919 influenza pandemic. PLoS One. 2010;5(7):e11655.
10. Lemon J. Hospital in Brooklyn looks like a “war zone”, emergency room doctor
says: “we’re fighting for our own lives too.” Newsweek.
https://www.newsweek.com/hospital-brooklyn-looks-like-war-zone-emergency-
room-doctor-says-were-fighting-our-own-1495007. Updated March 30, 2020.
Accessed May 16, 2020.
11. Report on Residents: Table B3: Number of Active Residents, by Type of Medical
School, GME Specialty, and Sex: 2017-18 Active Residents. Association of
American Medical Colleges. https://www.aamc.org/data-reports/students-
residents/interactive-data/table-b3-number-active-residents-type-medical-school-
gme-specialty-and-sex. Updated August 27, 2018. Accessed May 16, 2020.
12. Accreditation Council for Graduate Medical Education: About Us.
https://www.acgme.org/About-Us/Overview. Accessed May 16, 2020.
13. Vargo E, et al. Cleveland Clinic Akron general urology residency program’s
COVID-19 experience [published online April 2, 2020]. Urology.
https://doi.org/10.1016/j.urology.2020.04.001.
24
14. Stoj VJ, Grant-Kels JM. Dermatology residents and the care of patients with
coronavirus disease 2019 (COVID-19). J Am Acad Dermatol. 2020;82(6):1572-
1573.
15. Canelli R, Connor CW, Gonzalez M et al. Barrier enclosure during endotracheal
intubation. N Engl J Med. 2020;382(20):1957-1958.
16. Yu AY, Tu R, Shao X, et al. A comprehensive Chinese experience against
SARS-CoV-2 in ophthalmology [published online April 7, 2020]. Eye Vis (Lond).
https://doi:10.1186/s40662-020-00187-2.
17. Wu P, et al. Characteristics of ocular findings of patients with coronavirus
disease 2019 (COVID-19) in Hubei Province, China [published online March 31,
2020]. JAMA Ophthalmol. https://doi: 10.1001/jamaophthalmol.2020.1291.
18. Wang W, et al. Detection of SARS-CoV-2 in different types of clinical specimens
[published online March 11, 2020]. JAMA. https://doi:10.1001/jama.2020.3786.
19. Xie C, et al. Comparison of different samples for 2019 novel coronavirus
detection by nucleic acid amplification tests. Int J Infect Dis. 2020;93:264-267.
20. Bendavid E, Mulaney B, Sood N, et al. COVID-19 antibody seroprevalence in
Santa Clara County, California [preprint].
https://doi:10.1101/2020.04.14.20062463. Posted on medRxiv April 14, 2020.
25
FIGURES:
Figure 1. Flow-chart of survey recruitment and responses among greater New York City
training programs, including represented specialties and number of residents. ACGME =
Accreditation Council for Graduate Medical Education; PDs = training program directors.
26
Figure 2. Of 2,088 total residents with known COVID-19 testing status, 101 residents
were confirmed (positive), 163 were presumed (untested), 76 were suspected
(negative), and 1,748 neither had symptoms nor were tested.
27
Figure 3. Number of residents with new COVID-19 symptoms by week. Most confirmed
COVID-19 cases (N = 35) were reported during the week of 3/23- 3/29. Most presumed
COVID-19 cases (N= 53) and suspected COVID-19 cases (N = 29) were reported a
week earlier than the peak of confirmed cases during 3/16 – 3/22. Total number of
confirmed, presumed and suspected COVID-19 cases all started to drop after the week
of 3/23 -3/29. Bottom panel shows the number of programs enforcing mask policy by
week. Most programs started to enforce universal mask policy during the week of 3/23 –
3/29.
28
Table. Number and percentage of symptomatic residents with confirmed (positive),
presumed (untested), and suspected (negative) COVID-19 testing across specialties.
Specialty # Residents # Confirmed # Presumed # Suspected Vascular Surgery Anesthesiology
13 282
4 (30.8%) 21 (7.4%)
1 (7.7%) 19 (6.7%)
0 (0.0%) 12 (4.3%)
Emergency Medicine Radiation Oncology Ophthalmology Otolaryngology Plastic Surgery Physical Medicine and Rehabilitation Obstetrics and Gynecology Dermatology Pathology General Surgery Psychiatry Family Medicine Neurological Surgery Neurology Internal Medicine Diagnostic Radiology Pediatrics Urology Child Neurology
382 56 177 40 62 88 90 81 27 252 146 83 48 48 119 90 126 58 13
25 (6.5%) 3 (5.4%) 9 (5.1%) 2 (5.0%) 3 (4.8%) 4 (4.5%) 4 (4.4%) 3 (3.7%) 1 (3.7%) 9 (3.6%) 5 (3.4%) 2 (2.4%) 1 (2.1%) 1 (2.1%) 2 (1.7%) 1 (1.1%) 1 (0.7%) 0 (0.0%) 0 (0.0%)
32 (8.4%) 3 (5.4%) 17 (9.6%) 3 (7.5%)
17 (27.4%) 4 (4.5%) 7 (7.7%) 1 (1.2%) 1 (3.7%) 16 (6.3%) 10 (6.8%) 3 (3.6%) 1 (2.1%) 4 (8.3%) 5 (4.2%) 5 (5.6%) 2 (1.6%) 7 (12.1%) 4 (30.8%)
12 (3.1%) 2 (3.6%) 7 (4.0%) 2 (5.0%) 0 (0%)
1 (1.1%) 1 (1.1%) 7 (9.2%) 0 (0.0%) 13 (5.2%) 5 (3.4%) 7 (8.4%) 4 (8.3%) 1 (2.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (8.6%)
Nuclear Medicine 5 0 (0.0%) 1 (20.0%) 1 (20.0%) Oral/Maxillofacial Surgery 18 0 (0.0%) 0 (0.0%) 0 (0.0%) Medical Genetics 2 0 (0.0%) 0 (0.0%) 0 (0.0%) Total 2306 101 (4.4%) 163 (7.1%) 76 (3.3%)
